Under-dilated TIPS Associate With Efficacy and Reduced Encephalopathy in a Prospective, Non-randomized Study of Patients With Cirrhosis

Schepis, Filippo; Vizzutti, Francesco; García–Tsao, Guadalupe; Marzocchi, G; Rega, Luigi; Maria, Nicola De; Maira, Tommaso Di; Gitto, Stefano; Caporali, Cristian; Colopi, Stefano; Santis, M. De; Arena, Umberto; Rampoldi, Antonio; Airoldi, Aldo; Cannavale, Alessandro; Fanelli, Fabrizio; Mosconi, Cristina; Renzulli, Matteo; Agazzi, Roberto; Nani, Roberto; Quaretti, Pietro; Fiorina, Ilaria; Moramarco, Lorenzo Paolo; Miraglia, Roberto; Luca, Angelo; Bruno, Raffaele; Fagiuoli, Stefano; Golfieri, Rita; Torricelli, Pietro; Benedetto, Fabrizio Di; Belli, Luca; Banchelli, Federico; Laffi, Giacomo; Marra, Fabio; Villa, Erica

doi:10.1016/j.cgh.2018.01.029

Cited by 94 publications

(84 citation statements)

References 21 publications

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“…34,35 Growing evidence has been published that suggests less complications after TIPS by using smaller diameter stents or dilatation of stents smaller than the nominal diameter, suggesting a beneficial effect of less shunt volume. [36][37][38][39][40] Regarding other decompensating events, we were unable to find a significant difference in variceal bleeding, hepatorenal syndrome or spontaneous bacterial peritonitis between patients with L-TSA and S-TSA. Considering variceal bleeding, our data are supported by previous reports, in which only the presence of SPSS vs. no SPSS was shown to be associated with bleeding, but no differences between small and large SPSS were detected.…”

Section: Discussioncontrasting

confidence: 60%

Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis

Praktiknjo

Simón-Talero

Römer

et al. 2020

Journal of Hepatology

101

100

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Section: Discussioncontrasting

confidence: 60%

Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis

Praktiknjo

Simón-Talero

Römer

et al. 2020

Journal of Hepatology

101

100

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“…These findings are in contrast to the recommendation of the Italian National Consensus Guideline 5 and a recent study from Italy showing that underdilation persisted and resulted in less HE. 21 Fortunately, an improved covered stent has been marketed recently (Viatorr CX) that allows stent adjustment to 8, 9, or 10 mm without spontaneous further selfexpansion. In any case, our results encourage dilation to 8 mm as a routine, independent of the degree of reduction of the pressure gradient, and to revise and dilate further if necessary.…”

Section: Discussionmentioning

confidence: 99%

Smaller-Diameter Covered Transjugular Intrahepatic Portosystemic Shunt Stents Are Associated With Increased Survival

Trebicka

Bastgen

Byrtus

et al. 2019

Clinical Gastroenterology and Hepatology

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BACKGROUND & AIMS: We studied the effects of diameter of covered, self-expandable, nitinol stents on survival times of patients with a transjugular intrahepatic portosystemic shunt (TIPS). METHODS: We collected data from 185 patients (median age, 55 y; 30% female) who received a covered nitinol stent, from February 2006 through September 2010, using the online multicenter German TIPS registry. TIPS were given to 107 patients for refractory ascites and to 78 patients for variceal bleeding. Patients at risk of hepatic encephalopathy (owing to advanced age, prior episodes) or liver failure (bilirubin level, >3 mg/dL), and bleeding patients receiving variceal embolization at TIPS, received 8-mm stents (n [ 53). The remaining patients received 10-mm stents (n [ 132). Eighty-one of the 10-mm stents were underdilated using 8-mm dilation balloons. Clinical and biochemical data were collected after TIPS placement at 1 month, 3 months, 6 months, 9 months, 1 year, and thereafter every 3 to 6 months. Groups were compared using propensity score analysis. RESULTS: Patients who received 8-mm stents survived significantly longer (34-26 mo) than patients who received 10-mm stents (18-19 mo), regardless of whether they were fully dilated or underdilated. When we compared 10-mm stents with or without underdilation, we found that a significantly higher proportion of patients who received underdilated stents survived for 1 month after TIPS placement (95% vs 84%; P [ .03), but not for 3 months (P [ .10). In multivariate analysis, 1-year mortality correlated with full dilation of the stent to 10 mm (hazard ratio [HR], 2.0; 95% CI, 1.1-3.5) and with serum creatinine concentration at baseline (HR, 1.5; 95% CI, 1.0-1.7). Five-year mortality was associated with use of the 10-mm stents (HR, 1.8; 95% CI, 1.4-2.7) and baseline concentration of creatinine (HR, 1.3; 95% CI, 1.1-1.6). CONCLUSIONS: A smaller stent (nominal diameter of 8 mm, but not underdilation of a 10-mm stent) is associated with a prolonged survival compared with 10-mm stents, independent of liver-specific prognostic criteria.

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“…From the experience with H-graft calibrated shunts we know that 8 mm shunts were significantly better than large shunts (12 mm and above). 6,21 For TIPS, it has recently been reported that under-dilated covered TIPS (dilated to up to 6-7 mm in diameter) may cause less encephalopathy than "standard" diameter TIPS (8-10 mm in diameter), 22 but this is based on a single non-randomised retrospective study with a rate of overt hepatic encephalopathy of 54% at 1-year with standard TIPS (in the upper reported range) and of 26.9% with under-dilated TIPS. Moreover, the study reported no spontaneous dilation of the selfexpandable stents, which contrasts with the results of studies conducted over longer observation times.…”

Section: Current Challengesmentioning

confidence: 99%

Small diameter shunts should lead to safe expansion of the use of TIPS

Bosch

2021

Journal of Hepatology

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Transjugular intrahepatic portosystemic shunt (TIPS) is increasingly used worldwide to treat the complications of portal hypertension in patients with advanced cirrhosis. However, its use is hampered by the risk of causing hepatic encephalopathy and of worsening liver function. The reported haemodynamic targets used to guide TIPS are too narrow to be achieved in most cases and are perhaps not entirely adequate nowadays as they were obtained in the pre-covered stent era. We propose that small diameter TIPSalone or combined to pharmacological therapy or ancillary interventional radiology proceduresmay overcome these limitations while maintaining the beneficial effects of the procedure.

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Under-dilated TIPS Associate With Efficacy and Reduced Encephalopathy in a Prospective, Non-randomized Study of Patients With Cirrhosis

Abstract: In prospective, non-randomized study of patients with cirrhosis, we found under-dilation of PTFE-SGs during TIPS placement to be feasible, associated with lower rates of PSE, and effective.

Cited by 94 publications

References 21 publications

Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis

Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis

Smaller-Diameter Covered Transjugular Intrahepatic Portosystemic Shunt Stents Are Associated With Increased Survival

Small diameter shunts should lead to safe expansion of the use of TIPS

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